P A Access to Healthcare and the ADA

P A Access to Healthcare and the ADA

P A Access to Healthcare and the ADA A Review of the Case Law The development of this presentation was funded, in part, from a subcontract with the Great Lakes ADA Center, University of Illinois at Chicago ADA National Network Webinar Series September 26, 2019 Presented by: Barry C. Taylor Equip for Equality

1 Outline of todays presentation Which law applies? Is facility a healthcare provider? Legal standing to bring ADA cases against healthcare 2 providers DOJ and access to healthcare Effective communication in the healthcare setting Access to healthcare for people living with HIV

Access to healthcare for people with service animals Accessible medical facilities and equipment Administration and use of medication Info related to ADA issues arising for healthcare workers Todays presentation does not address ADA issues for 3 healthcare workers with disabilities. (Title I of the ADA) However, Equip for Equality has developed a legal brief through a grant with the Great Lakes ADA Center that addresses a number of employment-related issues impacting healthcare workers, including essential job functions, reasonable accommodations, undue hardship, direct threat, confidentiality, wellness plans, and doctors as independent contractors.

That brief can be found at: www.equipforequality.org/wpcontent/uploads/2018/09/ADA-and-Healthcare-Workerswith-Disabilities.pdf P A Which Law Applies? Titles II, III or Rehab Act? 4 Which law applies? Titles II, III or Rehab Act? Almost all healthcare organizations are covered by either 5

Title II or Title III of the ADA, as well as Section 504 of the Rehabilitation Act. Which law depends on whether healthcare provider is public or private, and whether it receives federal funding. Title II Applies to public healthcare providers Title III Applies to private healthcare providers (In Title IIIs listing of public accommodations, healthcare provider and hospital are specifically listed) Rehabilitation Act Applies to hospitals that are recipients of federal funding ADA v. Rehab Act General Rule: What is prohibited by Titles II or III of the ADA is also prohibited by the Section 504 Differences:

6 Regulations: HHS issues regulations for Section 504, but DOJ issues regulations for Titles II and III of the ADA Compensatory Damages: Section 504 - compensatory damages available because healthcare provider waived defense of sovereign immunity when it accepted the federal funds. Title III of the ADA no compensatory damages permitted in statute Title II of the ADA - compensatory damages statutorily permitted, and recoverable for intentional discrimination Are Religious Healthcare Providers Subject to the ADA or Rehab Act? Reed v. Columbia St. Marys Hospital, 915 F.3d 473 (7th Cir. 2019) Background: Patient with tardive dyskenesia filed Title III

7 suit alleging hospital deliberately withheld from her the device she used to speak and put her in a seclusion room as punishment Hospital: Covered by ADAs religious exemption 7th Circuit: Religious exemption is an affirmative defense and hospital waived that defense by not raising it in its Answer Are Religious Healthcare Providers Subject to the ADA or Rehab Act? But see Cole v. Saint Francis Medical Center, 2016

8 WL 7474988 (E.D. Mo. Dec. 29, 2016) - religious exemption properly raised and hospital was under jurisdiction of the Bishop of the Roman Catholic Dioceses, not ADA Remember Even if religious exemption applies, healthcare provider may be liable under Rehab Act if entity receives federal funding P A Is Facility a Healthcare Provider? 9 Is facility a place of public

accommodation under Title III? 10 General Rule: Traditional healthcare providers covered by Title III, but less clear with non-traditional healthcare providers Silguero v. CSL Plasma, Inc. 907 F.3d 323 (5th Cir. 2018) CSL Plasma is a plasma collection center Pays anyone who passes screening test to donate plasma 2 people excluded due to mobility disabilities and service animal Issue: Is CSL Plasma a place of public accommodation? 5th Cir: No. Affirmed MSJ not a service establishment Service implies benefit to customers and no benefit here Service establishment doesnt pay customer But see ,Matheis v. CSL Plasma, 2019 WL 4125222 (10th Cir. Aug. 30, 2016) (finding plasma center a service establishment) P

A ADA Coverage for Healthcare Providers 1 1 Legal standing to bring ADA suit against healthcare providers 12 General Standing Requirements - Constitution Plaintiff must suffer a personalized and concrete injury-infact of a legally cognizable interest The injury must be traceable to the defendants conduct It must be likely, rather than speculative, that the injury can be redressed through a favorable court decision Standing Requirements Title III of the ADA Plaintiff must show harm from lack of ADA compliance

Accessibility issues must relate to the plaintiffs disability Must show a likelihood of future harm this is the most common issue in Title III legal standing challenges Standing to sue allegation of future harm Many courts have adopted the following 4 factors for demonstrating likelihood of future harm: Proximity of the business to the plaintiffs home, Plaintiffs past patronage of the defendants business, Definiteness of the plaintiffs plans to return, and Frequency of travel near the business. Many people with disabilities unable to pursue healthcare discrimination case because of a finding of lack of standing. 13 Legal standing found in case against healthcare providers Alexander v. Kujok,

158 F.Supp.3d 1012 (E.D. Ca. 2016) Deaf man denied interpreter by 6 in-network doctors Out-of-network doctor provided interpreter - but more 14 expensive ADA suit filed against 6 doctors offices - they argued no standing because could not show likelihood of future harm Court: Plaintiff had standing because he alleged that he would return to in-network physician if accommodation was provided because of higher expense of out-of-network dr. Plaintiff does not have to engage in futile gesture if he already knows accommodation wont be provided. Legal standing not found in case against healthcare provider Juech v. Childrens Hosp. & Health Sys., Inc., 2018 WL 5775918 (E.D. Wis. 2018)

15 Woman who is deaf brought her daughter to ER video remote interpreting service malfunctioned; staff not trained She filed ADA suit against hospital Court: Dismissed case no legal standing. Plaintiff failed to allege a real and immediate threat of violations of her legal rights. There were six closer hospitals so unlikely she would return to this hospital. No one never intends to return to an emergency room and that plaintiff had not returned since the initial incident. P A DOJ Efforts to Enforce Access to Healthcare

1 6 DOJ Barrier-Free Healthcare Initiative In 2012, the U.S. Department of Justice launched its 17 Barrier-Free Healthcare Initiative, a partnership between U.S. Attorneys and DOJs Civil Rights Division. More info about the Barrier-Free Healthcare Initiative can be found at www.ada.gov/usao-agreements.htm Over 50 Settlements are listed on DOJs website

Common elements of DOJ settlement agreements: Policy revisions to ensure the provision of the appropriate auxiliary aids and services, including sign language interpreters and materials in alternate formats DOJ Barrier-Free Healthcare Initiative Common elements of DOJ settlement agreements: Perform communication assessment, requiring consulting with the patient and documenting the decision in the patients chart Signage about available auxiliary aids/services Training requirements

Recent settlements Pro-Medica Health System (8/29/19) www.ada.gov/promedica_health_systems_sa.html 18 Lincare, Inc. (7/3/19) www.ada.gov/lincare_sa.html Hazelden Betty Ford Foundation (6/28/19) www.ada.gov/ hazelden_betty_ford_sa.html P A ADA and Effective

Communication in the Healthcare Setting 1 9 In-person American Sign Language interpreters By far, the most common access to healthcare ADA cases involve effective communication DOJ guidance: Interpreters v. exchange of written notes - 28 C.F.R. Pt. 35, App. A. Written notes may be OK when conversation is minimal (routine lab tests or regular allergy shots) Interpreters should be used when communication is more complex (medical history, diagnoses, procedures, treatment decisions, and communications regarding at-home care) 20

Courts: Most courts have found when deaf individual who uses ASL needs to communicate about a complicated medical procedure, especially a surgery, the exchange of written notes is an inadequate way to achieve effective communication In-person American Sign Language interpreters Liese v. Indian River County Hospital District 21 701 F.3d 334 (11th Cir. 2012) Discrimination claim brought by husband and wife who are both deaf Wife had emergency procedure to remove her gallbladder

Despite requesting an interpreter, communication about procedure only done by mouthing words, writing notes, and pantomiming. Trial Court: Found in favor of hospital 11th Cir: Sufficient evidence that limited auxiliary aids provided were ineffective; reversed decision granting summary judgment See also, more recent DOJ settlement with Overlake Hospital www.ada.gov/overlake_sa.html, in which hospital failed to provide interpreter during deaf womans childbirth and her mother was forced to interpret, meaning dad couldnt participate in the birth. Case finding interpreter not required Martin v. Halifax Healthcare Sys., Inc. 2015 WL 4591796 (11th Cir. July 31, 2015) Deaf patient had a brief emergency room visit for a bump on the head not provided with an interpreter 11th Cir: Affirmed summary judgment for hospital Interpreter was not necessary because plaintiff received typed

instructions, which the patient, who is able to read and write English, indicated he understood Note: ASL and English are not the same, so some deaf people may be fluent in ASL but unable to read English, making passing notes ineffective even for communications that are not complex 22 Access to healthcare: ASL interpreter access Title II U.S. v. Washington State Healthcare Authority 23 www.ada.gov/wshca_sa.html

Healthcare Authority (HCA) administers Washington States Medicaid program HCA claimed it provided ASL interpreters for Medicaid recipients medical appointments, but in actuality, interpreters often not available As a result, people needing interpreters had to cancel or re-schedule medical appointments or proceed without an interpreter Settlement: HCA will enter into contract with Interpreter Services Provider that has at least 100 qualified interpreters covering the geographic regions of the entire state Must meet at least 90% of ASL interpreter requests Must meet technical standards if using Video Remote Interpreting Effective communication in healthcare not limited to deaf patients Vast majority of healthcare ADA effective communication cases involve patients who are deaf However, requirement to provide effective

communication extends to all disabilities Reed v. Columbia Saint Mary's Hospital 782 F.3d 331 (7th Cir. 2015) Reed has tardive dyskinesia which limits her ability to 24 speak uses a communication device to communicate During a hospital visit for mental health issues, she was denied access to her communication device Court: Viable ADA complaint that healthcare provider failed to provide effective communication VRI vs. In-person interpreters DOJ Regulations include Video Remote Interpreting (VRI) VRI: Connects an off-site interpreter through the use of a

25 video conferencing system to facilitate communication Performance standards: 28 C.F.R. 36.303(f); 28 C.F.R. 35.160(d) Must have high-speed, wide-bandwidth video connection required to prevent low-quality video images Must provide adequate staff training to ensure quick set-up and operation of the machine For a sample DOJ agreement applying these performance standards, see DOJ Agreement with Mountain States Health Systems at www.ada.gov/mountain_state_sa.html VRI vs. In-person interpreters Potential problems: DOJ: When individual cannot access screen because of vision loss or because of positioning due to injury www.ada.gov/effective-comm.htm

NAD: Concerned about overreliance, technological problems, lack of adequate training www.nad.org/issues/technology/vri/position-statement-hospitals Shaika v. Gnaden Huetten Memorial Hospital 26 2015 WL 4092390 (M.D. Pa. July 7, 2015) The Hospitals VRI did not work, so staff used written notes to communicate to the plaintiff that her daughter had passed away Court: Denied motion to dismiss with respect to whether the hospital had acted with deliberate indifference to the plaintiffs rights, but see Horan v. Univ. Hosp., 2019 WL 1767063 (N.D. Ohio Apr. 22, 2019)

VRI vs. In-person interpreters Silva v. Baptist Health South Florida 856 F.3d 824 (11th Cir. 2017) Plaintiffs alleged that Hospitals persistent use of VRI violated the 27 ADA because of technical difficulties or practical limitations Ex: Machine was inoperable or unusable, picture would be blocked, frozen or degraded, staff dont know how to use it District Court: Hospital provided effective communication No evidence of misdiagnosis or improper medical treatment Plaintiffs failed to identify what they failed to understand Plaintiffs lacked standing to seek injunctive relief Appeal: DOJ amicus brief www.justice.gov/crt/file/870846/download 11th Cir: Found for plaintiffs (reversed/remanded MSJ) VRI vs. In-person interpreters

ADA/Rehab Act claims are not the same as medical malpractice Focus is on communication itself not the consequences of the failed communication Question: Did patient experience a real hindrance, due to her disability, affecting her ability to exchange material medical information with her health care professionals? Here, Plaintiffs provided evidence that they were hindered due 28 to issues with VRI and lack of in-person interpreters Plaintiffs are not required to identify exactly what information they were unable to understand or convey Cites DOJ regulations re: VRI Plaintiffs had standing because they regularly used the Hospital,

lived nearby and were likely to return Video Remote Interpreting (VRI) Morales v. Saint Barnabas Medical Center 13-cv-06363 (D.N.J. Consent Order - 2017) For VRI, must meet DOJ regulatory requirements examples: High quality video images; sharp and large image VRI shall not be used when it is ineffective examples: Inability to see, move head/hands/arm, limited cognition, or pain Information exchanged is highly complex Area without a designated high speed Internet line Space restrictions in room where patient is treated Time limit: VRI not operational after staff try for 45 minutes If VRI is not effective, must provide onsite interpreter If VRI is used, will confirm it is meeting individuals needs 29

Coverage of companions It is well settled that the ADAs effective communication obligations extend to companions with disabilities Definition of companion: [A] family member, friend, or associate of an individual accessing either the public entity or place of public accommodation, who, along with such individual, is an appropriate person with whom the [public entity or public accommodation] should communicate 28 C.F.R. 35.160(a)(1) (Title II) 28 C.F.R. 36.303(c)(1)(i)(Title III) Note: There has not been significant litigation disputing 30 whether an individual qualifies as a companion, perhaps because of the broad definition of the term companion

Coverage of companions Most cases accept that the individual is a companion, and then determine whether the communication provided was effective. Perez v. Doctors Hosp. at Renaissance, Ltd., 2015 WL 5085775 (5th Cir. Aug. 28, 2015) Parents, who are deaf and required sign language interpreters for effective communication, were entitled to protection of Section 504, at hospital where their son was a patient. DOJ Settlement: Fairfax Nursing Center, Inc Complainants: 83-year-old residents daughter and granddaughter 31 requested ASL interpreters, but the request was denied Settlement: Nursing Center agreed to provide appropriate auxiliary

aids and services to both patients and their companions http://www.ada.gov/fairfax_nursing_ctr_sa.html Companions v. association discrimination Issue: Can a non-disabled family member bring a claim for discrimination under the ADA for association discrimination? Loeffler v. Staten Island University Hospital 582 F.3d 268 (2d Cir. 2009) Hearing children of deaf patient and patients wife forced to 32 interpret during their fathers hospital stay Court: Children suffered an independent injury related to hospitals failure to provide interpreter for their parents But see, McCullum v. Orlando Regional Healthcare System, Inc. 768 F.3d 1135 (11th Cir. 2014), no discrimination claim for nondisabled family members who interpreted for deaf patient. Nondisabled persons could show no independent injury (distinguished

from Loeffler where kids missed school to interpret for parents) DOJ regulations on family member interpreting DOJ regs (effective 2011): 28 C.F.R. 36.303(c)(4); 28 C.F.R. 35.160(c) Cannot use an adult to interpret/facilitate communication except emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available OR individual specifically requests that accompanying adult provide the interpretation, adult agrees, and reliance is appropriate Cannot use a minor child to interpret/facilitate communication except

33 emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available Talking prescription containers Structured Negotiation with CVS/Pharmacy Structured negotiations with the American Foundation for the 34 Blind, American Council of the Blind, and California Council CVS/pharmacy provides ScripTalk talking prescription labels for Rx Great demonstration of the various types of auxiliary aids and

services that can lead to effective communication, especially with the advance of new technologies www.lflegal.com/2014/03/cvs-prescription-agreement Other similar talking prescription container settlements can be found at: www.lflegal.com/category/settlements/accessible-health-caresettlements/ Access to healthcare: alternative formats Figueroa v. Azar (HHS/CMS) 35 16-cv-30027 (D. Mass. settlement reached April 2019) Alleges HHS violated Section 504 by denying blind Medicare beneficiaries meaningful/equally effective access to Medicare info Settlement CMS will: Ensure communications/notices from Medicare are available in accessible formats (ex: large print, Braille, audio, electronic) Provide accessible, fill-able forms on Medicare.gov

Issue best practices to Medicare Health/Drug Plans Implement a policy that extends the time a beneficiary must answer time-sensitive communications to account for the time it takes to process requests for alternate formats Promote the availability of accessible materials to beneficiaries www.browngold.com/medicare-information-accessible-blind-beneficiaries Effective communication digital information Access to healthcare is not limited to the physical 36 facilities of healthcare providers and direct personal interactions with their representatives, but also applies to healthcare providers digital communications Numerous settlements see for example: Massachusetts Eye and Ear Institute Agreement www.lflegal.com/2017/01/meei-agt

WellPoint Accessible Information Agreement www.lflegal.com/2014/02/wellpoint-agreement/ Digital health information recent cases filed Mazrui v. U.S. Office of Personnel Management, 1:19-cv-6249 (N.D. Ill. filed Sept. 19, 2019) Retired blind federal employee and NFB sued U.S. OPM and Blue Cross Blue Shield for refusing to ensure that digital health benefits information under the Federal Employee Program is accessible to blind people. Meyer v. Walthall, 1:19-cv-3311 (S.D. Ind. filed Aug. 6, 2019) Lawsuit alleging the Indiana Division of Family Resources 37 (that handles SNAP and Medicaid applications) is

inaccessible and the state is failing to provide effective communication to people who are blind or low vision, including an inaccessible internet portal. P A Access to Healthcare for People Living with HIV/AIDS 3 8 Direct threat and HIV Supreme Court sets standard Historically, people living with HIV/AIDS have faced

39 significant stigma and discrimination, including in the healthcare context. Discrimination continue today. Bragdon v. Abbott, 524 U.S. 624 (1998) A dentist refused to treat a patient with HIV alleged patient posed a direct threat to the dentists safety Supreme Court: In determining direct threat, healthcare providers must make an individualized inquiry as to the circumstances of the particular plaintiff, and rely only on most recent objective medical evidence, without deferring to individual subjective judgments HIV discrimination in healthcare still prevalent United States v. Asare, 2017 WL 6547900 (S.D.N.Y. Dec. 20, 2017) Cosmetic surgeon excluded patients with HIV and/or on meds

Court: Found for plaintiffs (granted motion for summary judgment) Eligibility criteria that screens out people with disabilities and is not necessary Defendants burden to show exclusion is necessary cant meet burden because he automatically reject[s] patients 40 Even if risk, failed to make reasonable modifications Plaintiff proposed adjusting sedative protocol, hiring anesthesiologist to monitor/assist, etc. Fundamental alteration fails no individualized inquiry HIV discrimination in healthcare still prevalent DOJ: In recent years, DOJ has entered into numerous settlements with healthcare providers who discriminated against people with HIV. For example, see: Woodlawn

Family Dentistry: www.ada.gov/woodlawn_fmly_dnst.htm DOJs work in this are can be found at: www.ada.gov/hiv/index.htm Typical provisions of settlement agreements: 41 Adopt and implement a non-discrimination policy Ongoing monitoring by DOJ ADA training for staff and administrators. Financial settlements for aggrieved parties involved Links to additional DOJ agreements related to HIV and healthcare

Advanced Plastic Surgery Solutions www.ada.gov/adv_plastic_surgery_sa.html Pain Management Care www.ada.gov/pmc/pain_mgmt_care_cd.html North Florida OB/GYN Associates www.ada.gov/north_florida_sa.html Dentex Dental Mobile www.ada.gov/north_florida_sa.html

Genesis Healthcare System www.ada.gov/genesis_healthcare_sa.htm Glenbeigh Alcohol Treatment Center www.ada.gov/glenbeigh.htmc 42 Fayetteville Pain Center www.ada.gov/fayetteville_pain_ctr_settle.htm P A Access to Healthcare for

People with Service Animals 4 3 ADA and service animals in the healthcare context DOJ Guidance on service animals references healthcare facilities: 44 in a hospital it would be inappropriate to exclude a service animal from areas such as patient rooms, clinics, cafeterias, examination rooms, and all other areas of the facility where

healthcare personnel, patients, and visitors are permitted without taking added precautions. may be appropriate to exclude a service animal from operating rooms or burn units where the animal's presence may compromise a sterile environment providers may not impose blanket bans against service animals without engaging in the interactive process in an earnest effort to identify potential reasonable accommodations www.ada.gov/service_animals_2010.htm ADA and service animals in the healthcare context - litigation Tamara v. El Camino Hospital 964 F. Supp. 2d 1077 (N.D. Cal. 2013) Psychiatric patient denied service animal while hospitalized Hospital argued service animal in a psych unit would pose a 45

direct threat anticipated harness could be used as a weapon and presence of the animal might upset other patients Court: Potential risks were merely speculative no individualized assessment conducted by hospital that showed plaintiff or her service animal actually posed the anticipated risks. Even if the hospitals perceived risks were real no reasonable accommodation analysis was conducted to ameliorate the risks ADA and service animals in the healthcare context - litigation Roe v. Providence Health System-Oregon, 655 F. Supp. 2d 1164 (D. Oregon 2009) Court: Direct threat for a hospital patient to use a service dog 46

with a putrid odor that resulted in patient transfers. The dogs size and growling response made it difficult for staff to treat patient and a handler was not always available. Dog may have had an infection as well. Hospital offered a compromise by requesting that patient close her door when the dog was present and offered to provide a HEPA filter. Plaintiff refused offer. Court dismissed case, and enjoined her from bringing any service animal to the hospital if she returned. Court noted that the hospital had a history of accommodating service animals. ADA and service animals in the healthcare context - ambulances Hardin County Emergency Medical Services Complaint filed with DOJ: Service animal not permitted to accompany man in Hardin Co. ambulance Settlement : www.ada.gov/hardin_ems_sa.html hire ADA Coordinator permit service animals to accompany owners in ambulance

unless animal out of control or not house broken no surcharge will be assessed for service animals only permissible questions about service animals will be asked ADA training for personnel 47 Service animals companions and mootness Sheely v. MRI Radiology Network, P.A., 505 F.3d 1173 (7th Cir. 2007) Medical facility violated the ADA by preventing blind mom from bringing service dog into MRI suite during sons appointment Court rejected that companions arent covered by Title III just because they arent the patient and dont receive a benefit from the public accommodation. MRI facility modified its no-animal policy soon afterwards However, court held that plaintiffs ADA suit was not mooted by

new policy unclear that wrongful behavior wouldnt recur See also, Hurley v. Loma Linda University Medical Center, 2014 WL 48 580202 (C.D. Cal. Feb. 12, 2014) ADA protects companions with service animals at healthcare facilities www.usdoj.gov/crt/ada/whc.htm P A Accessible Medical Facilities and Equipment 4 9

Federal guidance on accessible medical facilities and equipment DOJ Guidance: 2010 DOJ published guidance health care providers Sets forth responsibilities of health care providers to make their services and facilities accessible to individuals with mobility disabilities and provide reasonable modifications www.ada.gov/medcare_mobility_ta/medcare_ta.htm Access Board Standards:

50 2017 Access Board issued Standards for Accessible Medical Diagnostic Equipment Dont have force of law until fed agency adopts in own regs However, important guidance for healthcare providers on how to make equipment accessible www.adatitleiii.com/2017/01/u-s-access-board-issues-standardsfor-medical-diagnostic-equipment/ DOJ settlements on accessible healthcare facilities and equipment Beth Israel Deaconess Medical Center Allegations: inaccessible inpatient rooms and bathrooms insufficient inaccessible exam tables and medical equipment inaccessible routes and maneuvering space for

patients in wheelchairs Settlement - www.ada.gov/bidmsa.htm hire ADA compliance officer ensure that 10% of patient rooms are accessible ensure that 10% of examination and treatment equipment is accessible each building must have at least one accessible entrance 51 Accessible medical facilities and equipment through structured negotiations and private settlements Structured Negotiations: Non-litigation strategy has been successful in making medical facilities and medical equipment accessible to people with disabilities. For ex: UCSF Medical Center http://www.lflegal.com/2008/09/ucsf-settlement-agreement/ Massachusetts General Hospital and Brigham and

Womens Hospital http://www.lflegal.com/2009/06/boston-press/ Private Settlement Example: Metzler v. Kaiser, one of the first 52 comprehensive ADA settlements with major healthcare provider, www.equipforequality.org/wp-content/uploads/2018/09/KaiserSettlement.pdf ADA litigation focusing on accessible facilities and equipment Luna v. Americas Best Contacts and Eyeglasses, Inc., 1:11-cv-01783 (N.D. Ill. Complaint filed Mar. 15, 2011) Class action by wheelchair users unable to receive eye exam due to inaccessible exam rooms and equipment at 337 stores Settlement Terms:

53 Retain ADA Consultant to perform accessibility surveys and monitor remediation efforts ADA training for all personnel Updated policies and procedures for treating pwds Each store must have: a chair glide, accessible eyeglass and contacts fitting locations, and accessible exam room www.equipforequality.org/wp-content/uploads/2018/09/AmericasBest-Stipulation-and-Class-Settlement-Agreement.pdf P A Administration or Use of

Medication 5 4 Administration of medication In recent years, DOJ has undertaken numerous 55 enforcement actions on behalf of children with insulindependent diabetes and other disabilities to help ensure that those children enjoy equal access to places of public accommodation Children with insulin-dependent diabetes have found themselves effectively excluded by institutions that were unwilling to modify their policies in order to provide basic diabetes management care. The needs of children with diabetes differ, but these children generally need

assistance with blood glucose monitoring and with the administration of insulin and emergency medication. Administration of medication DOJ Agreement with Kindercare 56 www.ada.gov/kinder_care_sa.html (Sept. 2018) Kindercare operates 1,800 facilities for child care and camp Kindercare refused help administer insulin via syringe/pen Settlement Agreement: Kindercare will: evaluate reasonable modification requests on an individualized basis using objective evidence and current medical standards Agree that where a parent/guardian & physician/health care professional say OK for child to be assisted by a layperson,

training child care staff to help with routine care (including insulin by pen, syringe or pump) is generally reasonable Contact all families who were denied this request in past year Revise/publicize new policy, including sample diabetes plan Provide range of training (managers, teachers, child-specific) Administration of medication DOJ Settlement with Camp Bravo (June 2015) Camp refused to admit camper with epilepsy who required emergency medication for seizures Settlement: Camp will train staff to administer Diastat Adopt Seizure Emergency Action Plan and Physicians Order for the administration of Diastat so that it has individual instructions Provide training to staff responsible for camper with epilepsy

DOJ: It is the United States position that it generally will be a 57 reasonable modification by title III of the ADA for certain public accommodations, such as camps and child care service providers, to train laypersons to administer Diastat. www.ada.gov/camp_bravo_sa.html But see, U.S. v. NISRA, 168 F.Supp.3d 1082 (N.D. Ill. 2016) Opioid use DOJ Agreement with Selma Medical Associates

58 www.ada.gov/selma_medical_sa.html Complainant uses Soboxone to treat opioid use disorder (OUD) Tried to schedule an appointment at this family practice Selma Medical turned him away due to Suboxone use; informed complainant that this was per policy DOJ conclusions: Complainant is a person with a disability because he has OUD Discriminated against solely due to use of Suboxone Policy imposed eligibility criteria; no policy modifications Settlement (Dec. 2018) $30,000 damages; $10,000 civil penalty Revise policy; publicize on website, in reception, to employees Train its managers and employees who interact with patients P A


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